Third-Party Review Process Called Effective, Underused

Health plan enrollees who take their complaints about coverage issues to an independent reviewer have a good chance of getting HMO decisions overturned — but very few people take advantage of this system. One expert says that this is an indication that a Patients' Bill of Rights might not raise insurance premiums as much as many in the industry have stated it would.

Researchers at Georgetown University's Institute for Health Care Research and Policy examined the external review process in 41 states and Washington, D.C., and found that the boards overturned 45 percent of HMO rulings denying coverage.

The system is not used much, however. In New York, for instance, the state with the most appeals, only 10.7 cases per 100,000 were filed.

The findings of the report — "Assessing State External Review Programs and the Effects of Pending Federal Patients' Rights Legislation" — released by the Kaiser Family Foundation, may have taken policy makers by surprise, but it sure wasn't news to Ron Pollack, president of Families USA, a consumer health advocacy organization. He believes that consumers are intimidated by the appeals process.

"I think that these external, independent appeals are extremely important, because they provide an opportunity for recourse when somebody feels that they've been improperly denied care," says Pollack. "Unfortunately, this recourse is a meaningless remedy if the consumer does not have somebody available to help him with these hearings."

When Pollack refers to help, he means having someone actually represent consumers in appeals.

"For this very important right to an appeal to become meaningful, it will become increasingly important for consumers to have access to ombudsmen and other advocates who can help them present their claims as effectively as possible," says Pollack.

The report found that one reason many people do not appeal to a third-party review board is that many states mandate that they go through a health plan's internal review process first.

There was also the matter of filing fees and the minimum limits on the amount that must be in dispute.

"External review programs have earned broad support but they are not being widely used," says Drew E. Altman, president of the Kaiser Family Foundation. "The low number of cases suggests that a Patients' Bill of Rights might not raise insurance premiums as much as some have feared."